Proposal Form Financial Institutions Professional Liability Insurance

Transcription

1 Name of Insurance Company to which application is made Proposal Form Financial Institutions Professional Liability Insurance NOTICE: THIS IS A CLAIMS-MADE POLICY. EXCEPT AS MAY BE OTHERWISE PROVIDED HEREIN, THE COVERAGE OF THIS POLICY IS LIMITED TO LIABILITY FOR WRONGFUL ACTS FOR WHICH CLAIMS ARE FIRST MADE WHILE THE POLICY IS IN FORCE AND WHICH ARE REPORTED TO THE INSURER, AS SOON AS PRACTICABLE, BUT NO LATER THAN SIXTY (60) DAYS AFTER THE TERMINATION OF THE POLICY. PLEASE READ AND REVIEW THE POLICY CAREFULLY. THE LIMIT OF LIABILITY AVAILABLE TO PAY LOSS, INCLUDING JUDGMENTS OR SETTLEMENTS, SHALL BE REDUCED BY DEFENSE EXPENSES. FURTHER NOTE THAT DEFENSE EXPENSES SHALL BE APPLIED AGAINST THE APPLICABLE RETENTION AMOUNT. THE POLICY DOES NOT PROVIDE FOR ANY DUTY OR OBLIGATION ON THE PART OF THE INSURER TO DEFEND THE INSURED. As an attachment to this Proposal, please include the following: Latest two annual reports, including statements of condition, earning statements and reserve for loan loss statements. Latest quarterly interim statement of condition, earnings statement and reserve for loan losses. Latest 10-K and 10-Q Reports filed with the SEC. 1) a. Name of Applicant Address b. Number of Directors Officers & Employees of Applicant c. Date established (including any predecessor firm) Note: If more than one entity is to be insured, attach a separate sheet stating name and relationship of each entity more than 50% owned, indicating type of operations, date acquired or created, domestic or foreign, and Name of Parent. EO 00 R , The Hartford Page 1 of 13

2 2) a. Year Trust Department established b. Number of Branches with Trust Department c. Number of Officers in Trust Department d. Number of Employees (Excluding Officers) in Trust Department 3) With respect to all Trust Accounts, please complete the following: Non-dis Market cretionary/ Value # of Discre- Custodial of Assets Accounts tionary Advisory a. Individual (Trust, Estates, Etc.) % % b. HR-10 & IRA Plans % % c. ERISA Fiduciary Plans (a) Outside Plan * % % (b) In-house Plans % % d. Non-ERISA Pension Plans, % % Etc. e. Other Institutional % % f. All other accounts % % (Specify) * ("Outside" ERISA Plans are those sponsored by firms outside the Applicant' s own parent-subsidiary group.) 4) With respect to the Corporate Trust Division, please complete the following. (Please include amounts pertaining to the Mutual Funds and attach the latest Prospectus for each fund): # of Accounts Asset Value a. Transfer Agent b. Registrar c. Dividend Disbursing Agent d. Fiscal or Paying Agent e. Trustee under Bond EO 00 R , The Hartford Page 2 of 13

3 Indenture f. Escrow Agent (not involving exercise of discretion, or active management) g. Mutual Fund Shareholder Account: # of Funds # of Shareholder Accounts h. Automatic Dividend Reinvestment Service: # of firms for whose stock the service is offered # of Shareholder accounts i. Other (specify) 5) Does the Trust Department perform Trustee, Management or Advisory functions with respect to the Farms, Ranches, or other Real Estate, Oil, Gas or other mineral leases or interests, including Timber or Client Corporations or business where the Trust Department is involved in actual operations? Yes No Please describe, giving for each applicable category, the number of clients and the percentage to total Trust Department revenues derived. 6) Does the Applicant manage any Common Trust Funds? Yes No If Yes, please complete the following: NAME OF TRUST FUNDS MARKET VALUE OF ASSETS EO 00 R , The Hartford Page 3 of 13

4 Please submit the latest Annual Report for each fund. 7) Does the Applicant control 5% or more of the stock of any corporation via the operations of its Trust Department? If so, attach listing and describe means by which control in the Trust Department was obtained (e.g. through individual purchases or in a single block through an existing trust or estate). Yes No 8) a. Does the Applicant in any Department recommend investments in, or have involvement with, specialty areas other than commonly traded securities? (Specialty areas include Real Estate, Mortgages, Precious Metals, Commodity or other Futures, Restricted Securities, Oil and Gas Joint Ventures, Cattle Trusts or Limited Partnerships of any type.) Yes No b. If Yes, please describe which specialty area and state its percentage of total investments. 9) Does the Applicant act as an Investment Counselor? Yes No If Yes, please complete the following and submit a copy of the Discretionary Management Agreement. Market Number of Asset Value Accounts a. Discretionary Accounts: ERISA Defined Benefit Plans (Except HR-10' s and IRA' s) $ ERISA Defined Contribution Plans $ HR-10 and IRA Plans $ Non-ERISA Pension & Employee Benefit Plans $ Mutual Funds $ REITS $ All other Accounts $ Accounts for which Applicant is Trustee $ Total Book Value of all accounts $ EO 00 R , The Hartford Page 4 of 13

5 b. Non-Discretionary Accounts: ERISA Defined Benefit Plans (Except HR-10' s and IRA' s) $ ERISA Defined Contribution Plans $ HR-10 and IRA Plans $ Non-ERISA Pension & Employee Benefit Plans $ All other Accounts $ Total Book Value of all accounts $ 10) With respect to the Employee Retirement Income Security Act of 1974: a. If a Defined Benefit Plan and more than 10% of the assets are investments in securities or real property of the Sponsor Organization and/or its subsidiaries, outline procedures to be implemented to reduce this amount. b. If any other prohibitive transactions exist, what steps has the fiduciary taken to comply with the Employee Retirement Security Act of 1974? 11) With respect to clients other than custodial accounts: a. How often are financial reports rendered to various clients? b. Does the Applicant have an "approved" list of securities which can be recommended to all clients? Yes No 12) What approximate percentage of annual income is derived from the following: Trust Department Municipal Bond Department Foreign Exchange EO 00 R , The Hartford Page 5 of 13

6 Commercial Loans (Domestic) (Foreign) Installment Lending Retail Banking (Deposits) Wholesale Banking Loan Servicing Credit Card Operations Non-Banking Subsidiaries Mortgage Banker Subsidiary Finance Co. Subsidiary Discount Brokerage Services Investment Counseling Electronic Data Processing Other (Specify) 13) a. What Electronic Funds Transfer System (EFTS) does the Applicant have or subscribe to? b. Does the Applicant have an EFTS allowing customers direct access to the System? If Yes, please describe and include a copy of the contract with these customers. Yes No c. What coverage for EFTS exposures is available under the Applicant' s Bankers Blanket Bond? d. Does the Applicant act as a service bureau for corporate customer? Yes No If Yes, please support details, including a copy of the service contract. EO 00 R , The Hartford Page 6 of 13

7 14) General Description of Data Processing IN HOUSE OR SERVICE CLASS YES NO SERVICE BUREAU a. Demand Deposit b. Commercial Deposit c. Time Deposit d. Retail Loans e. Commercial Loans f. Letters of Credit g. Funds Transfer h. Foreign Exchange Dealings i. Securities Transfer j. Securities Custody k. Miscellaneous/Other 15) Automated Clearing a. Do you engage in a system of clearing debits and credits electronically through an automated clearing house or association? Yes No b. Do you use such a system to direct deposits of recurring government payments and business payrolls as well as automated bill payments, such as insurance premiums, mortgage payments, etc.? Yes No Identify the Automated Clearing System to which you belong. (Please attach a copy of the Agreement) 16) Does the applicant provide Management Services to customers via computer link? Yes No If Yes, please describe the various functions? EO 00 R , The Hartford Page 7 of 13

8 17) With respect to real property for which any department or subsidiary is responsible: a. State total value of all such properties b. State total number of locations c. Are insurance matters connected with these properties reviewed annually and appraisals marketed every three years? Yes No (Please describe) d. To the best of the Applicant' s knowledge, are all such properties adequately insured? Yes No (If No, please explain) e. Attach a schedule of properties valued at more than $300,000. Give locations and estimated insured amount. 18) List non-banking services performed for customers (Example: EDP, Accounting, Architectural, Insurance, Travel Agency, Brokerage, etc.) List prior and current year annual revenues ($) derived from such services. 19) a. Has any other entity been merged into, or acquired by, the Applicant within the last five (5) years? Yes No b. Has the Applicant publicly revealed that it has under consideration at the present time any acquisitions, tender offers or mergers? Yes No If Yes, give details. c. Was any acquisition or merger the result of any arrangement by a regulatory agency? Yes No If Yes, please give details and explain the terms of acquisition or merger. EO 00 R , The Hartford Page 8 of 13

9 20) a. What regulatory agencies have examination authority over Applicant and subsidiaries? b. How frequently are examinations performed? c. Date of last examination. d. State the total amount of all classified loans. e. Have all recommendations or criticisms of the last examination report been complied with as respects the Applicant and subsidiaries? Yes No If not, please explain (Attach separate sheet if necessary). f. Has the Applicant or any subsidiary ever received a cease or desist order from any regulator' s agency? Yes No If yes, indicate frequency and extent of. g. Internal Audit h. Outside Audit i. Firm 21) a. Name of Legal Counsel b. Name and address of any actuarial, consulting or other firms used by Applicant under contract. EO 00 R , The Hartford Page 9 of 13

10 22) With respect to other coverages presently carried by the Applicant, please complete the following: SELF INSURED CARRIER LIMIT TERM PREMIUM RETENTION a. Directors & Officers Liability b. Bankers Blanket Bond c. Pension Trust Liability d. Fiduciary Liability (ERISA) e. Data Processing Errors & Omissions f. Trust Department Errors & Omissions g. Safe Depository Legal Liability (please indicate if written on a voluntary pay basis) h. Mortgage Interest Errors & Omissions 23) With respect to the coverages described in Question 22, have any losses been paid by the carriers, or are there any losses which are expected to be paid by the carriers? Yes No If Yes, please give complete details. 24) a. Have any suits been made against the Applicant or any of its present or past Fiduciaries, Directors, Officers, Employees, Trustees, Pension Committee or Advisory Board Members of any of the Employee Benefit Plans? If none, so state. If Yes, please attach claims history showing number of claims and amount including defense costs and describe in detail any case exceeding $50,000. b. Provide details of any losses through negligence, errors or omissions involving any department or subsidiary. EO 00 R , The Hartford Page 10 of 13

11 25) No claim which, if insurance had ever been or were now in force similar to that now applied for, would have fallen within the scope of such insurance has been made or is now pending against any person proposed for insurance in the capacity of either Director, Officer, or Employee of the Applicant or is now pending against the Applicant, except as follows: If none, so state. 26) Does the Applicant or any of its Partners, Directors, Officers or Employees have any knowledge of any fact, circumstance or act which might give rise to a claim under the proposed policy? Yes No (If yes, attach full details): Pertaining to Questions 25 and 26 above, it is agreed that if the Undersigned or any Insured proposed for this insurance has knowledge of any such fact or circumstance or if such pending or prior claim or suit exists, then any claim or suit arising therefrom shall be excluded from coverage under the proposed policy. THE UNDERSIGNED AUTHORIZED OFFICER OF THE PROPOSAL DECLARES THAT THE STATEMENTS SET FORTH HEREIN ARE TRUE. THE UNDERSIGNED AUTHORIZED OFFICER AGREES THAT IF THE INFORMATION SUPPLIED ON THIS PROPOSAL CHANGES BETWEEN THE DATE OF THIS PROPOSAL AND THE EFFECTIVE DATE OF THE INSURANCE, HE/SHE (UNDERSIGNED) WILL, IN ORDER FOR THE INFORMATION TO BE ACCURATE ON THE EFFECTIVE DATE OF THE INSURANCE, IMMEDIATELY NOTIFY THE INSURER OF SUCH CHANGES, AND THE INSURER MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS AND/OR AUTHORIZATIONS OR AGREEMENTS TO BIND THE INSURANCE. SIGNING OF THIS PROPOSAL DOES NOT BIND THE APPLICANT OR THE INSURER TO COMPLETE THE INSURANCE, BUT IT IS AGREED THAT THIS PROPOSAL SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED AND IT WILL BE ATTACHED TO AND BECOME A PART OF THE POLICY. ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE INSURER IN CONJUNCTION WITH THIS PROPOSAL ARE HEREBY INCORPORATED BY REFERENCE INTO THIS PROPOSAL AND MADE A PART HEREOF. FRAUD WARNING STATEMENTS ARKANSAS APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. COLORADO APPLICANTS: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICY HOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICY HOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES. DISTRICT OF COLUMBIA APPLICANTS: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT." EO 00 R , The Hartford Page 11 of 13

12 FLORIDA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. HAWAII APPLICANTS: FOR YOUR PROTECTION, HAWAII LAW REQUIRES YOU TO BE INFORMED THAT PRESENTING A FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT IS A CRIME PUNISHABLE BY FINES OR IMPRISONMENT, OR BOTH. KENTUCKY APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. LOUISIANA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. MAINE APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS. NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES. NEW MEXICO APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES. NEW YORK APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY MATERIAL FACT THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL BE ALSO SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION. OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD. OKLAHOMA APPLICANTS: WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY. OREGON APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD OR SOLICIT ANOTHER TO DEFRAUD AN INSURER: (1) BY SUBMITTING AN APPLICATION OR; (2) FILING A CLAIM CONTAINING A FALSE STATEMENT AS TO ANY MATERIAL FACT MAYBE VIOLATING STATE LAW. PENNSYLVANIA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. EO 00 R , The Hartford Page 12 of 13

13 TENNESSEE: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS. VIRGINIA APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS. WEST VIRGINIA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. A POLICY CANNOT BE ISSUED UNLESS THE PROPOSAL IS PROPERLY SIGNED BY THREE INDIVIDUALS AND DATED. IF THE CHAIRMAN OF THE BOARD AND PRESIDENT ARE THE SAME INDIVIDUAL, PLEASE HAVE THE APPLICATION SIGNED BY A SENIOR VICE-PRESIDENT IN LIEU OF THE PRESIDENT. DATE DATE DATE SIGNATURE SIGNATURE SIGNATURE (Chairman of the Board) (President) (Chief Financial Officer or Treasurer) PLEASE SUBMIT THIS PROPOSAL AND APPROPRIATE MATERIALS TO: Hartford Financial Products 2 Park Avenue New York, N.Y EO 00 R , The Hartford Page 13 of 13